Department of Paediatric Neurosurgery, University of California, Davis, USA.
Great Ormond Street Hospital for Children, NHS Trust, London, UK.
Adv Tech Stand Neurosurg. 2023;47:145-214. doi: 10.1007/978-3-031-34981-2_6.
This review summarises the classification, anatomy and embryogenesis of complex spinal cord lipomas and describes in some detail the technique of total lipoma resection and radical reconstruction of the affected neural placode. Its specific mission is to tackle two main issues surrounding the management of complex dysraphic lipomas: whether total resection confers better long-term benefits than partial resection and whether total resection does better than conservative treatment, i.e. no surgery, for asymptomatic lipomas. Accordingly, the 24-year progression-free survival data of the senior author and colleagues' series of over 300 cases of total resection are compared with historical data from multiple series (including our own) of partial resection, and total resection data specifically for asymptomatic lesions are compared with the two known series of non-surgical treatment of equivalent patients. These comparisons so far amply support the author's recommendation of total resection for most complex lipomas, with or without symptoms. The notable exception is the asymptomatic chaotic lipoma, whose peculiar anatomical relationship with the neural tissue defies even our aggressive surgical approach, and consequently projects worse results (admittedly of small number of cases) than for the other two lipoma subtypes of dorsal and transitional lesions. Prophylactic resection of asymptomatic chaotic lipomas is therefore not currently endorsed. We have also recently found that some dorsal lipomas with clear outline of the conus on preoperative imaging had a significantly better long-term prognosis of preserving neurourological functions without surgery. Whether this subset of lipomas should be managed conservatively until symptoms arise is now an open question awaiting a longer follow-up of a larger cohort of such patients.
这篇综述总结了复杂脊髓脂肪瘤的分类、解剖和胚胎发生，并详细描述了全脂肪瘤切除术和受累神经基板的根治性重建技术。它的具体任务是解决复杂发育不良性脂肪瘤治疗管理中的两个主要问题：全切除术是否比部分切除术带来更好的长期获益，以及全切除术是否比无症状脂肪瘤的保守治疗（即不手术）更好。因此，高级作者及其同事对 300 多例全切除术的 24 年无进展生存数据进行了分析，并与多组（包括我们自己的）部分切除术的历史数据进行了比较，还将无症状病变的全切除术数据与两种已知的等效患者非手术治疗系列进行了比较。到目前为止，这些比较充分支持了作者对大多数复杂脂肪瘤（有症状或无症状）进行全切除术的建议。唯一的例外是无症状混沌脂肪瘤，它与神经组织的特殊解剖关系甚至使我们积极的手术方法也无法应对，因此其结果比其他两种脂肪瘤亚型（背侧和过渡性病变）更差（尽管病例数量较少）。因此，目前不推荐预防性切除无症状混沌脂肪瘤。我们最近还发现，一些术前影像学上有明确圆锥轮廓的背侧脂肪瘤，如果不手术，保留神经功能的长期预后明显更好。这部分脂肪瘤是否应该在出现症状之前进行保守治疗，这是一个悬而未决的问题，需要对更大的此类患者队列进行更长时间的随访。
